Diabetes controversy results in Mexican stand-off

Controversy has raged over the HB District Health Board’s decision not to renew the diabetes treatment contract of popular diabetes specialist Dr Janet Titchener.

Are HB diabetes patients being deprived of best available care? Or is the DHB making a prudent, clinically-driven decision to use its limited resources to up-skill more doctors and nurse specialists to give equally high quality care to a substantially growing number of diabetes sufferers?

For now, the controversy seems to have subsided into a Mexican stand-off, with no clear winner.

More on the outcome in a moment, but here’s the background, reflecting Baybuzz interviews with all the key players.

Background

Dr Titchener has treated over 1,000 diabetes patients in Hawke’s Bay. And to say her patients are passionate about her is an understatement.

Many regard her contribution to their (or a family member) gaining control over their diabetes as having transformed their lives. Often they credit her with succeeding after other caretakers, notably clinicians at the DHB, have failed. To them she’s a diabetes Wonder Woman. And they are alarmed that her services might not be available to themselves, their families, and more broadly, the community. What in the world is the DHB thinking, they ask.

Speaking for herself, Dr Titchener confidently asserts that she in fact can document improvements in her patients’ diabetes status (as measured by decreased blood sugars) that are exceptional and persistent. She challenges the DHB to document better performance on their part.

Executives and clinicians at the DHB take a different view.

Although generally acknowledging Dr Titchener’s capabilities and track record, they are firmly confident that DHB now offers an excellent quality of service to many more patients, many with a challenging array of diabetes-related complications that must draw upon a wider range of clinicians operating as a team. DHB CEO Kevin Snee emphasizes that providing the best medical care today is a “team game”.

Simple comparisons of patient blood sugar reductions, DHB clinicians say, do not do justice to the more complicated cases that the DHB diabetes clinic must treat … to say nothing of the often lesser self-management motivation of many of those patients. Nor do critics recognize the significant strides in improving diabetes care at the primary care level, particularly in the past two years since the adoption of a stakeholder-developed diabetes care strategy.

In support, according to DHB clinicians, for every ‘transformed’ and satisfied patient the Titchener camp can produce, the DHB can produce one as well. Tit for tat.

To the clinicians at DHB, as good as Dr Titchener is, the “extraordinary” resources that have been allocated to her practice can be better deployed to provide a high level of effective service to a diabetes population that now numbers 8,000 … and will soon grow to 10,000.

Moreover, DHB parties say, Dr Titchener has been fully welcome to apply to participate in the DHB’s treatment scheme – focused at the GP and specialist nurse level, mainly in larger clinics around the region – but has elected not to do so. They say she has shown no inclination to work ‘within the system’, when offered opportunities to do so. To which Titchener supporter Andy Lowe responds, referring to DHB’s Kevin Snee: “He said his staff will not work with her.”

Is this a simple matter of a ‘talented but vexatious’ square peg not fitting in a round hole? Or does one individual’s $150,000 contract dispute, almost insignificant in an institution with a $450 million budget, carry larger import?

Who’s ‘in the right’ here?

The Mexican Stand-off

Businessman Andy Lowe, responding to the alarm of several of his diabetes-afflicted employees who were satisfied Titchener patients, rallied to her cause. Dismayed by what he regards as the unresponsiveness of the DHB over several meetings, he has come to the rescue of Dr Titchener, at least for the next twelve months.

He will subsidise a ‘pilot programme that allows Dr Titchener to provide diabetes care training to 15 doctors and 17 nurses at Totara Health (initially), and probably to four additional clinics in Hastings, Napier, Wairoa and CHB. Meanwhile, she will continue her private practice.

Motivating patient behaviour change is a key aspect of Dr Titchener’s approach, and her supporters regard her as peerless in this regard. As Andy Lowe sees it, Dr Titchener has “shown them up” (referring to the DHB clinicians). He expects the proof of Dr Titchener’s superior efficacy will be seen in the number of GP’s (and nurses) who choose to avail themselves of her training and/or refer diabetes patients to her … and to the patient outcomes they will produce.

At the DHB, clinicians insist their diabetes service, independently evaluated, ranks as one of the best in New Zealand. They bristle at the suggestion that their service is anything less. Moreover, they argue, the training programme the DHB is now providing doctors and nurses throughout the region, focusing first on larger-scale practices that see the most patients, will yield better health outcomes for a much larger portion of the population.

Setting aside the personalities, it appears that neither side disagrees on the fundamental strategy:

• Patient self-care or self-management is pivotal to successfully addressing this disease; and,
• The best opportunity to educating patients and motivating the needed behavior change (and providing additional intervention if needed) for the thousands of patients involved is at the GP primary care level.

So now diabetes patients in Hawke’s Bay will have a choice between two competing services. The question that remains on the table — hence, the Mexican stand-off — is whether one service or the other will deliver better outcomes over the coming year.

Like it or not, fairly or unfairly, Team Titchener/Lowe has thrown the competitive gauntlet down to the DHB and Health Hawke’s Bay (the region’s Primary Health Organisation), effectively saying ‘we can do better’. In so doing, they call into question the efficacy of the DHB’s approach.

Team DHB may regard that as totally unjustified and, in fact, a disservice if the claim wrongly undermines public confidence in the DHB-led service. But that’s the reality they will need to deal with over the coming year. The time is gone when patients/consumers will simply follow any ‘voice of authority’ out of sheer deference or passivity. The ball is in the court of the DHB and Health Hawke’s Bay to establish what they — and independent observers — regard as the appropriate metrics for evaluating the two services.

Our community will be very poorly served if mutual anger prevails, and the metrics and processes are not in place to make a proper evaluation when the time comes. And when the comparison is made, it must be made with full transparency.

Maybe there will be an outright ‘winner’. Maybe both will demonstrate excellent outcomes.

Maybe the competition will force each will lift the other’s game. And perhaps that’s the only upside to this dispute.

As one onlooking GP observes, it’s unfortunate that irreconcilable personalities are involved, but hopefully this rocky path will benefit patients, which is where the focus should be.

Stay tuned!

Tom Belford